Med Mgmt Nurse

Medical Management Nurse

Location:

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month.

The Federal Employee Program (FEP) provides health benefits to federal employees, retirees, and their families. Through its longstanding partnership with the federal government, FEP offers nationwide coverage and access to a broad network of providers, with a focus on delivering quality, affordable care.

• Utilizes nursing judgment and reasoning to analyze members' clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.
• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members' aggregate symptoms and information.
• Assesses member clinical information and recognizes when a member may not be receiving the appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provide consultation to the Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.
• Collaborates with case management nurses on discharge planning, ensuring the patient has the appropriate equipment, environment, and education needed to be safely discharged.
• Collaborates with and provides nursing consultation to the Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.
• Serves as a resource to lower-level nurses.
• May participate in interdepartmental teams, cross-functional teams, projects, initiatives, and process improvement activities.
• Educates members about plan benefits and physicians and may assist with case management.
• Collaborates with leadership in enhancing training and orientation materials.
• May complete quality audits and assist management with developing associated corrective action plans.
• May assist leadership and other stakeholders on process improvement initiatives.
• May assist with training lower-level clinician staff.

• Requires a minimum of associate's degree in nursing.
• Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
• Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
• Multi-state licensure is required if this individual is providing services in multiple states.

• Certification in the American Association of Managed Care Nurses is preferred.
• Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
• Leadership skills are strongly preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED >
Licensed Nurse